medicine – ToewsTravels

medical walking tour of edinburgh

mcewan hall, university of edinburgh, edinburgh, scotland

surgeon hall museums, edinburgh, scotland

ann gifted me a privately guided walking tour of edinburgh for my birthday! there is an outsized history of medicine and medical discoveries in edinburgh, and it was very fascinating. the tour began at the greyfriars kirkyard, which is a ancient cemetery in the center of edinburgh. there, metal cage-like barriers would be placed over recent graves to prevent grave robbers from stealing recently deceased bodies, which they could sell as cadavers, which were in high and unregulated demand in the early days of formalized medical education.

we then proceeded to mcewan hall, the home of the medical school at the university of edinburgh. many important medical discoveries were made in edinburgh, including the etiology of scurvy by james lind, and many others.

the next stop was the meadows, a large open area of grass on the campus of the university of edinburgh. beneath the meadows are thousands of unmarked graves, as this was were bodies were buried during the bubonic plague. reportedly, occasionally students and tourists relaxing on the grass still find pieces of human bones sifting up from beneath the earth.

another stop was the surgeon hall museums, the first anatomy and pathology museum in the world. this is also where there was a riot in 1870 in support of the “edinburgh seven,” seven women who agitated for the right to study medicine at the medical school when women were not allowed to do so. unfortunately, it took an inordinate amount of time even after these riots for the medical schools to begin to allow women to matriculate.

we also went to the old surgeon’s hall at the university of edinburgh, which was a cadaver lab in the early days of formal medical education. private cadaver labs were started as educational competition/supplementation to the medical school, and to supply cadavers, they would need to be purchased, often under questionable circumstances, such as being snatched from recent graves. robert knox ran one of the most well known cadaver labs, where he would dissect the freshest cadavers for the education of medical students. at least 16 of these bodies were procured from william burke and william hare, who had murdered their victims for this purpose. we also walked by the medical lecture hall of joseph lawrence, the father of modern surgical sterilization, the inventor of listerine, and the founder of the johnson and johnson company.

the tour ended at the old college of the university of edinburgh, where there is a nondescript plaque in honor of one the british military’s most famous surgeons for decades of the 1800s, james barry, who served all over the world and tremendously improved sanitation standards. the fascinating thing about james barry was that they were actually a woman, whose real name was margaret ann bulkley, a fact not realized by anyone else until after her death. it was an era in which women were not permitted to practice medicine. the plaque and all the military records still read “james barry.”

protetcion against grave snatchers, greyfriars kirkyard, edinburgh, scotland

plaque commemorating james lind, who discovered the etiology of scurvy, mcewan hall, university of edinburgh, edinburgh, scotland

plaque commemorating the edinburgh seven, surgeons hall museums, edinburgh, scotland

medical school at the university of edinburgh, edinburgh, scotland

2 weeks of pediatric emergency medicine and critical care at kijabe hospital, kenya

kijabe hospital emergency department, kijabe, kenya

i was able to do the final global health rotation of my medical education at kijabe hospital in kenya for 2 weeks of volunteering and teaching! kijabe hospital is growing, medium-sized rural mission hospital on the edge of the great rift valley about 1 hour north of nairobi, and has developed a reputation as one of kenya’s best hospitals. i spent 3 months volunteering at this hospital back in college, so it was a special experience to be able to return now, 10 years later, as a pediatric emergency medicine fellow. there have been amazing strides made in the medical education offerings at the hospital, and it is now has numerous training programs, including a surgery residency, nursing program, clinical officer (kenyan equivalent of physician assistant) and medical officer (kenyan equivalent of medical internship) programs, and more! impressively, it is also one of a few teaching sites for a new pediatric emergency medicine (pem) and critical care fellowship program, which is the first and only program of its type in africa!

i spent some time with the kenyan pem/critical care fellow rotating at the hospital that month, as well as a lot of time supervising and teaching the clinical officers and medical officers in the emergency department and the 10-bed pediatric intensive care unit. they loved learning and loved my lectures, which was great! i was able to give a number of lectures on burn management, pediatric advanced life support, pediatric abdominal emergencies, seizure management and more. and i was able to lead rounds in the intensive care unit, and did a number of nights as the pediatric attending on call.

as one might expect, rural kenya remains a very resource limited setting, though kijabe hospital has many more resources than almost anywhere else in sub-saharan africa. their 3 pediatric ventilators provide an almost unheard-of abundance for a hospital in the region, yet they are still not enough for the number of patients who need a ventilator, which is always tough. through donations, the hospital is able to cover inpatient medical costs for many families who cannot afford care, which most hospitals do not do. the pathology in rural kenya is much more advanced than in the west, and patients often present very late in the disease course.

pediatric emergency department, kijabe hospital

pediatric intensive care unit, kijabe hospital

it was also fascinating to learn about differences in medical management in africa compared to the west, and not just those one might expect due to resource limitations. for example, a mainstay of treatment in the west for sepsis, an overwhelming blood infection, is aggressive resuscitation with fluids. however, a landmark, large, blinded randomized controlled study in east africa (the feast trial) revealed that aggressive fluid resuscitation is associated with worse outcomes in this setting, so fluid resuscitation is used very judiciously throughout africa, which is a complete paradigm shift from what had been considered sacrosanct in sepsis treatment for decades. the evidence-based treatment for severe acute malnutrition is also notably different in africa than in the west (where admittedly it is very rarely seen). in any case, for my pem fellowship senior lecture after i got home i talked about these differences for 1 hour as i think they are very fascinating!

the pediatric emergency medicine / critical care fellowship at kijabe is run by an inspirational american-trained pem named dr. ariana shirk, who has served at kijabe hospital for almost a decade. i truly appreciate her willingness to let me come out on short notice, and even provide me (and my wife ann for the second week) housing in a nice little guesthouse. i learned a lot from her. she is a true hero, and it is mindblowing to consider how many children’s lives have been saved either directly by her, or exponentially more-so by the countless providers she has trained over the years, who are now working throughout kenya and further afield in africa.

one funny story: we needed a portable xray on a patient. it was taking forever and we had called the xray tech multiple times, but they were saying the machine was too heavy for them to push it up some ramps to get to the icu. so i decided to go get it myself. it was a portable xray machine from about the 1950s, and did seem to weigh about 1 ton, and the wheels on it seemed very stiff. i struggled to push it up multiple ramps and down multiple hallways, finally arriving at the icu about 15 minutes later, sweating profusely. everyone started laughing, because apparently i had pushed this thing through the entire hospital without removing the brake. once that was off, it rolled easily!

medical education is definitely one of the best ways to go in terms of having a profound and sustainable impact in global health. i felt honored to have this opportunity to be involved at kijabe hospital and look forward to the next trip!

model of kijabe hospital. very impressive facility for rural sub-saharan africa

courtyard mid-day singing/worship, kijabe hospital

togo excursions

i was volunteering in togo through an ngo called world medical mission. while generally they are a great organization, they were super paranoid about not letting their volunteers use public transportation or even taxis, which is outrageous – as a result i am probably going to avoid volunteering with them again. on top of this, the hospital is in a very rural area without many nearby towns, so i didn’t get out as much as i would have liked to. oh well.

i was able to go on a few daytrips on the weekends. on one saturday a group of us visited visited a nearby boarding school for blind children, run by the same mission agency as the hospital. it is very cool – they provide great education for the children (and even adults), who are mostly blind due to trachomatis flies, the most common etiology of blindness in africa. they are taught braille at the school, and there are textured posters on the walls of the school for teaching various things like topography on maps and different organ systems of the body. they are also taught how to weave furniture which they can continue to do once they leave to provide a service to their communities. there are some new missionaries running the center who are really doing some great work there. they also have an aquaponics farm they showed us, where they grow tilapia fish and use the waste to grow plants such as lettuce and strawberries. we then went to a french restaurant in kpalime called chez fanny, which was pretty good.

one sunday myself and some medical students climbed one hour up a nearby mountain to attend a church up there. we were soaked with sweat upon arrival so needed to change. despite being at the top of a mountain without electricity, each of the approximately 20 people who showed up were wearing their sunday best. they were very welcoming. speaking of, it has been nice having the medical students around – there have been three of them at any given time. one is going into pediatrics so i have been able to do some teaching and he has been very helpful with our pediatric patients at the hospital.

on our last weekend, we took a long drive and then a long hike to wli falls, a very high waterfall right on the border with ghana. so – despite my previous successful endeavor to visit ghana, i got to step across the border again! we went swimming beneath the waterfall and the water falling hundreds of feet created a crazy wind tunnel of mist. it was great.

there has been a lot of fomenting unrest in togo while we’ve been here, with widespread protests against the autocratic leader, faure gnassingbe. between him and his father, the family has been ruling togo since the 1960s, and people are starting to get tired of it. compared to its immediate neighbors, togo is relatively poor. the reasons for this are of course multifactorial, but it is at least partially due to government mismanagement. there are weekly protests including in the nearby city of kpalime. these are generally very peaceful, but during some there have been people killed by government security forces. this is part of a wider trend across africa right now, dubbed the “african spring.” my amazing wife ann is actually writing about this while here, so has been traveling around the region while i’ve been at the hospital.

early morning departure, lome airport (brand new, chinese built)

lassa scare

about a week after arriving in togo, i examined a six year old girl who presented with about one week of fever, diarrhea, emesis, and diffuse abdominal pain. i didn’t think much of it, and didn’t use gloves, because they aren’t really readily available in the clinic unless you go looking for them. i have been using them since. we did some blood work, and admitted her to the hospital. she tested negative for malaria and typhoid fever, the two most common etiologies of fever here. she also had significant pancytopenia (low white blood cells, red blood cells, and platelets), which is strange. we started her on the empiric antibiotic treatment for typhoid fever, but after two days she continued to have persistently high fevers, and her three year old sister also started developing the same symptoms. her sister was found to have the same lab results, and both also had very high transaminase (liver enzymes) levels as well. all these symptoms are consistent with viral hemorrhagic fever, specifically a terrible disease called lassa fever. to top it off, the younger girl started having profuse blood in her stool.

lassa fever is an arenavirus endemic to certain parts of west africa, spread by the aerosolized urine of a certain species of rat, which come into people’s homes during the dry seasons. it can also be spread between people via any body fluids. it was first described in the 1970s, and was named after a city in northeastern nigeria where there was a major outbreak. it is a viral hemorrhagic fever similar to ebola and marburg virus, as in addition to the nonspecific symptoms of fever, abdominal pain, diarrhea, emesis, and throat pain, etc, it can also cause bleeding from mucosal membranes and hypovolemic shock and end organ failure. so pretty scary. it has even been cited as a potential agent for bioterrorism. about 80% of people who get it actually don’t get sick enough to be hospitalized, but the mortality rate is about 50% for those who need hospitalization. even more scary, well over 50% of nosocomial infections (person-to-person in a healthcare setting) are fatal.

there had never been a positive case of lassa fever in this part of togo before. however, antibody studies have been done suggesting that the majority of togolese have been exposed to the virus at some point, meaning it exists and just hasn’t been isolated, likely simply due to lack of testing. the first person confirmed to have died from lassa fever in togo was an american physician assistant who was working in a mission hospital in northern togo and fell ill last year. he continued to deteriorate, and was evacuated to germany, where he sadly died. they then discovered he had lassa fever. he didn’t have any known exposures, so no one really knows how he contracted it.

after the girls had been sick for a while and after much discussion among the hospital staff, it was decided to send a blood sample to the central lab of the government in lome to test for lassa fever. it became apparent that it is quite the process. the local authorities have to sign off on the test being done after a meeting, and a medical provider has to escort the blood sample all the way to lome as it is considered biohazardous. this all took the better part of a week to arrange. once the blood sample finally made it there the confirmatory test by pcr was relatively quick. i read everything on the internet about lassa fever. interestingly, a number of studies about transmission in exposed, unprotected individuals came out of germany last year after the missionary from togo was evacuated to there with what was then an undifferentiated illness. there is an antiviral medication which helps some once infected, but it doesn’t really work very well, and isn’t exactly available on short notice to a rural hospital in togo.

thankfully, the test came back negative! i must admit though, in the intervening days i was quite scared that i might get it (and if i did, more likely than not, die an agonizing death). because the disease starts with nonspecific symptoms like sore throat, diarrhea and fever, i was constantly thinking that i might be coming down with it. i prayed more frequently and fervently than i normally do. it was an important reminder for me of the fragility of life, and that life can end before we want it to, a reality that usually isn’t as apparent in the west as it is in africa. i really needed to trust in God, and be reminded that my faith in Him is all i really have that matters, and all i really need. there are so many frivolous concerns in our lives that just don’t really matter when you think you might die soon. thank you to my amazing wife who comforted me when i was really on edge. we still don’t know what the girls had, but it was almost certainly something viral and nasty. thankfully they started to do better and we were able to send them home.

first weeks in togo

as an elective during my third year of residency, i am able to do a month of global health! i arranged to come to togo, west africa. i am spending one month at the karolyn kempton memorial christian hospital, also called hospital baptiste biblique (hbb). it is a missionary-run hospital in tsiko, near adeta, togo, a rural area about 3 hours north of the capital lome. it is actually the second largest hospital in the country. on arrival in lome, the hospital had arranged a redundant “welcomer” to meet us prior to customs. she directed us to the wrong line, and then when customs guards asked for a bribe for one of our suitcases, advised us to pay it. we refused, and they eventually let us through without it.

in togo, good medical care is very hard to come by, so the services hbb provides are much appreciated. people in togo must generally pay up front for any hospital services, including emergent ones. even motor vehicle accident victims – even if obviously wealthy – are not resuscitated in emergency rooms until the medical providers are paid, leading to countless preventable deaths. widespread frustration over these practices are one of many drivers of recent protests against the autocratic government. hbb is unique in that they treat any presenting emergent patients first, then ask for payment later. they also supply medicines and supplies for inpatients, which contrasts with most hospitals in the country which require patients or their families to provide supplies and medicines, which they need to buy at markets outside the hospital. all the physicians at hbb are western missionaries (which makes it a good place to learn for a resident such as myself), though there are a staff of togolese physician assistants who see many of the patients in clinic and are the first call overnight. physicians, including myself while i am here, act more as consultants overnight, and do rounds on inpatients and see clinic patients during the day. everyone in the area are subsistence farmers, such that even just the meager salaries of the physician assistants and nurses have essentially created a middle class in the area. most of the locals are people belonging to the ewe tribe, which stretches across the west african countries of benin, togo, ghana and others. there are other tribes in the area as well, such as the fulani, who are more nomadic cattle herders and have their own language. they often come by the hospital, are told how much something like a small surgery will cost, leave, and come back a week or two later with the money, which is often a lot for this part of the world. we had one little fulani feeder-grower premature baby who had been there for weeks, requiring a special high-calorie formula and an incubator. every day it was someone’s job to explain to the grandmother why the baby needed to stay until they reached a certain weight, because they wouldn’t survive life on the road at their size.

i have seen some very interesting medical cases thus far. by far the most common diagnosis is malaria, which often causes severe anemia requiring blood transfusion and extreme splenomegaly. this is the diagnosis for well over half of the admissions. many children also get cerebral malaria which can cause altered mentation, seizures and coma/death. one of my patients died recently from this, likely a brain herniation. typhoid fever is also very common. one child had an intestinal perforation secondary to typhoid, which is a common complication. intestinal amoebiasis is also very common, as are hookworms which are often visible just beneath the skin. impressively, the hospital has developed treatment guidelines for many of these prevalent conditions, so diagnosing and treating them as a tropical medicine novice has not been as challenging as i might have expected before arriving here. there are also a large number of developmentally challenged children who present to the clinic, some already many months old, who have never been diagnosed and have never seen a medical provider before. many have traveled long distances, often even from neighboring countries, to come the hospital because of its reputation. sadly, most of the time there is not much we can do.

a common theme of medicine in the developing world is that people just take longer to present, so their pathology becomes more extreme. i saw a boy the other day whose toothache one year ago developed into indolent osteomyelitis of his jaw, completely reforming the shape of his face over the last year. likewise, many patients with cancer present very late with huge masses. because of the continued strong animism here, some children have scars from cutting attempts by local traditional healers for things like abdominal distension. many people also take “herbs” given to them by these healers, some of which the hospital staff are realizing cause liver failure and resultant uncontrolled bleeding from coagulopathy. there are also many premature infants, often born via caesarean, many of whom die because there are no ventilators if they have respiratory distress. there is the capacity to provide non-invasive positive pressure, however, and it is amazing how well some of them do. there are other cool work-arounds, like giving premature babies nescaffe instant coffee powder in their feeds instead of pharmaceutical caffeine to stimulate their respiration!

pediatrics ward, hospital baptiste biblique, tsiko, togo

emergency department, hospital baptiste biblique, tsiko, togo

mexico city!

in april i was lucky enough to be able to go to las vegas for the acep (american academy of emergency physicians) advanced pediatric emergency medicine assembly, which was of course an excellent conference! on my way home to philly, i decided to take a flight detour through mexico!

i had a layover in monterrey, mexico, during which i was excited to check out the vip lounge that i suddenly had access to thanks to my new credit card, but it was excessively crowded, to the point of multiple people sitting on each other’s laps.

i had two full days in mexico city, and it really hit the spot! great value for money, and a ton of things to do. i mostly just wandered around – huge, beautiful malls. there is a massive downtown park chulpuateca with many attractions including a colonial era castle with great views of the rapidly proliferating skyline. and, most famously, the excellent national museum of anthropology – one of the best museums i have ever been to! it is arranged around an open courtyard, with an iconic roof that has water falling from it. in the surrounding building is a very thorough history and present-day synopsis of mexico’s various regions, which are remarkably distinct from each other in many ways. a definite must see.

mexican national museum of anthropology, mexico city

i also went to the upscale polanco neighborhood which is where mexico city’s wealthy jewish and lebanese populations reside and shop, and downtown zocalo square, the third largest square in the world, which also has one of the largest flying flags in the world. nearby is the torre latinamericana, one of the tallest buildings in mexico city, which has a great viewing deck at its top. also perused some cathedrals and the place bella artes which is mexico city’s beautiful opera house, and the plaza girabaldi which is filled with mariachi bands at every time. and for the first time ever, on the flight home i got upgraded to first class!

mexico city from the torre latinamericana

somaliland!

i crossed overland from ethiopia, which was painless with my somaliland visa i had procured earlier in addis ababa. i waited for a little while at the bustling border area for my cousin, who lives in somaliland with his family, to come pick me up, along with his government-mandated armed guard.

somaliland is a de-facto independent state in the northwest of what the rest of the world considers somalia. it is a very stable, functioning, democratic entity that, in contrast to somalia proper, is very safe to visit! it was originally colonized by the british, while the rest of somalia was claimed by italy prior to independence. my cousin lives in a town called boramo, and we drove there through endless desert in his landcruiser. there are a few expatriates in boramo, and all live in walled compounds, which is the norm there. in addition to catching up with family, we explored some markets, and i went on a run through the dusty town. there is a university in the town, and a new nascent family medicine residency, which is great! i got to see the hospital, meet some of the residents, and even join them for rounds.

the last day we drove to the bustling capital hargeisa to fly out.

obviously somalia has a less than stellar reputation, and that is unfair to the vast majority of its people want nothing to do with al shabaab or pirating. the vast majority of people in somalia are basically just like the rest of us – trying to provide a better life for their families. the perception that all of somalia is lawless is especially damaging to somaliland, which is very safe – if the international community recognized somaliland, this would really help, as it is difficult for them to obtain foreign direct investment and the like while still technically being part of somalia. anyway, if you ever have the opportunity to visit somaliland don’t hold back, as it is a great place!

off the beaten path in amhara

from the moment we decided to visit ethiopia, we wanted to visit mikedes, a girl ann has sponsored through world vision. she lives in mersa, a little town in the amhara region about eight hours from the nearest airport. we figured we would arrange our transport there once in lalibela, and as things have a tendency to do in africa, that turned into a saga. we talked to a few travel fixer types in lalibela about our desires, and they all had many fanciful brochures and promises of luxury transport options. each of them basically had people following us around lalibela, asking us about our most recent plans for getting to the next town, and offering us different prices for jeeps, vans, etc. also comments about how the other guys wouldn’t come through. but when the time came to actually go, no one could come through. our guide addis in lalibela promised he could get us there by bus if he could come with, so we took the 5:30 am local bus with him from lalibela to weldia. it was an austere african journey, fjording streams and picking folks up every five minutes.

the folks from world vision met us at a hotel in weldia, about two hours after the agreed meeting time, but its all good. they had a van, and now things were official, so a guy from the government had to join us to keep an eye on us. so now we had three cooks in the kitchen – the world vision area director, the government minder, and our guide addis from lalibela. and as such, always three different views on what should happen next. we just sat back to see the turf war unfold!

before visiting our sponsor child, they insisted we see some world vision water projects in the area. then they took us to the local world vision office for a tour. apparently we were the only sponsors to ever have come to this place, and, they said, the first white people to visit the town in as long as they could remember. when they found out i was a physician they also brought us to a world vision-run local health clinic. then finally, we went to the mikedes’ house and met her and her father. her mother passed away so she cooks and keeps the house up for her and her father, who is a farmer. world vision allows her to attend school and pays for supplies, etc as well as food at school, which is great, as without that support she probably wouldn’t be able to attend school. they live in a mud hut with their ox outside, and we sat on their floor and drank some impeccably prepared ethiopian coffee and it was a really special time.

now that world vision could trust us, they offered to give us a ride all the way back to lalibela the next day. on the way we stopped for some kitfo, raw goat hamburger sprinkled with cayenne pepper. mmmmm!

with random children and our government minder, mersa

medical school graduation

medical school for international health (msih) class of 2015!

finally, it was time for graduation from medical school! our speaker was dr. ofri, a prominent writer and physician at new york university school of medicine. my friend ross gave a great speech, and then it was over. mazal tov/mabruk/congrats to my classmates; i wouldn’t have wanted to get through medical school with any other group of people!

soroka university hospital, ben-gurion university of the negev, beer sheva, israel

last weeks of medical school

my last three selectives were radiology, otolaryngology and orthopedics, each for two weeks. interesting stuff, and quite relaxed schedule which is very nice!

i’ve also been able to do some things which were on my bucket list, like visit the israel museum in jerusalem which house the dead sea scrolls. beer sheva finally has its first ethiopian restaurant (there are many ethiopians here so it is surprising that it took this long for someone to open a restaurant). last weekend went to a hot spring spa called neve midbar in the negev desert south of beer sheva with some bros, as well as made one more trip to the taybeh brewery in the west bank, which i must say is one of my favorite locales in this part of the world, for what it represents. as glad as i am to be moving on, there are things about here that i’ll really miss.